MD Travel Health - Peru - vaccinations, malaria, safety, and other medical advice

Summary You can't Edit

1

Summary of recommendations

Most travelers to Peru will need vaccinations for hepatitis A, typhoid fever, and yellow fever, as well as medications for malaria prophylaxis, travelers' diarrhea, and altitude sickness. Other immunizations may be necessary depending upon the circumstances of the trip and the medical history of the traveler, as discussed below. Insect repellents are recommended, in conjunction with other measures to prevent mosquito bites. All travelers should visit either a travel health clinic or their personal physician 4-8 weeks before departure.

Malaria:Prophylaxis with Lariam (mefloquine), Malarone (atovaquone/proguanil), or doxycycline is recommended for all areas below 2000 m (6561 ft), including the cities of Iquitos and Puerto Maldonado, with the exception of the cities of Ica, Lima, the coast south of Lima, and Nazca.

Vaccinations:

Hepatitis A	Recommended for all travelers
Typhoid	Recommended for all travelers
Yellow fever	Recommended for the entire regions of Amazonas, Loreto, Madre de Dios, San Martin, and Ucayali and designated areas of far northeastern Ancash; northern Apurimac; northern and northeastern Ayacucho; northern and eastern Cajamarca; northwestern, northern, and northeastern Cusco; far northern Huancavelica; northern, central, and eastern Huanuco; northern and eastern Junin; eastern La Libertad; central and eastern Pasco; eastern Piura; and northern Puno. For travel to the regions of Lambayeque and Tumbes and designated areas of west-central Cajamarca and western Piura, recommended only for those who at risk for a large number of mosquito bites. Not recommended for areas greater than 2300 m in elevation, areas west of the Andes not listed above, the cities of Cuzco and Lima, Machu Picchu, and the Inca Trail.
Hepatitis B	Recommended for all travelers
Rabies	For travelers spending a lot of time outdoors, or at high risk for animal bites, or involved in any activities that might bring them into direct contact with bats
Measles, mumps, rubella (MMR)	Two doses recommended for all travelers born after 1956, if not previously given
Tetanus-diphtheria	Revaccination recommended every 10 years

Revisions

Summary of recommendations
Most travelers to Peru will need vaccinations for hepatitis A, typhoid fever, and yellow fever, as well as medications for malaria prophylaxis, travelers' diarrhea, and altitude sickness. Other immunizations may be necessary depending upon the circumstances of the trip and the medical history of the traveler, as discussed below. Insect repellents are recommended, in conjunction with other measures to prevent mosquito bites. All travelers should visit either a travel health clinic or their personal physician 4-8 weeks before departure.
Malaria:Prophylaxis with Lariam (mefloquine), Malarone (atovaquone/proguanil), or doxycycline is recommended for all areas below 2000 m (6561 ft), including the cities of Iquitos and Puerto Maldonado, with the exception of the cities of Ica, Lima, the coast south of Lima, and Nazca.
Vaccinations:
<table class="table table-striped table-hover table-bordered">
<tbody>
<tr>
<td>Hepatitis A</td>
<td>Recommended for all travelers</td>
</tr>
<tr>
<td>Typhoid</td>
<td>Recommended for all travelers</td>
</tr>
<tr>
<td>Yellow fever</td>
<td>Recommended for the entire regions of Amazonas, Loreto, Madre de Dios, San Martin, and Ucayali and designated areas of far northeastern Ancash; northern Apurimac; northern and northeastern Ayacucho; northern and eastern Cajamarca; northwestern, northern, and northeastern Cusco; far northern Huancavelica; northern, central, and eastern Huanuco; northern and eastern Junin; eastern La Libertad; central and eastern Pasco; eastern Piura; and northern Puno. For travel to the regions of Lambayeque and Tumbes and designated areas of west-central Cajamarca and western Piura, recommended only for those who at risk for a large number of mosquito bites. Not recommended for areas greater than 2300 m in elevation, areas west of the Andes not listed above, the cities of Cuzco and Lima, Machu Picchu, and the Inca Trail.</td>
</tr>
<tr>
<td>Hepatitis B</td>
<td>Recommended for all travelers</td>
</tr>
<tr>
<td>Rabies</td>
<td>For travelers spending a lot of time outdoors, or at high risk for animal bites, or involved in any activities that might bring them into direct contact with bats</td>
</tr>
<tr>
<td>Measles, mumps, rubella (MMR)</td>
<td>Two doses recommended for all travelers born after 1956, if not previously given</td>
</tr>
<tr>
<td>Tetanus-diphtheria</td>
<td>Revaccination recommended every 10 years</td>
</tr>
</tbody>
</table>

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Medications You can't Edit

2

Medications

Travelers' diarrhea is the most common travel-related ailment. The cornerstone of prevention is food and water precautions, as outlined below. All travelers should bring along an antibiotic and an antidiarrheal drug to be started promptly if significant diarrhea occurs, defined as three or more loose stools in an 8-hour period or five or more loose stools in a 24-hour period, especially if associated with nausea, vomiting, cramps, fever or blood in the stool. A quinolone antibiotic is usually prescribed: either ciprofloxacin (Cipro) 500 mg twice daily or levofloxacin (Levaquin) 500 mg once daily for a total of three days. Quinolones are generally well-tolerated, but occasionally cause sun sensitivity and should not be given to children, pregnant women, or anyone with a history of quinolone allergy. Alternative regimens include a three day course of rifaximin (Xifaxan) 200 mg three times daily or azithromycin (Zithromax) 500 mg once daily. Rifaximin should not be used by those with fever or bloody stools and is not approved for pregnant women or those under age 12. Azithromycin should be avoided in those allergic to erythromycin or related antibiotics. An antidiarrheal drug such as loperamide (Imodium) or diphenoxylate (Lomotil) should be taken as needed to slow the frequency of stools, but not enough to stop the bowel movements completely. Diphenoxylate (Lomotil) and loperamide (Imodium) should not be given to children under age two.

Most cases of travelers' diarrhea are mild and do not require either antibiotics or antidiarrheal drugs. Adequate fluid intake is essential.

If diarrhea is severe or bloody, or if fever occurs with shaking chills, or if abdominal pain becomes marked, or if diarrhea persists for more than 72 hours, medical attention should be sought.

Though effective, antibiotics are not recommended prophylactically (i.e. to prevent diarrhea before it occurs) because of the risk of adverse effects, though this approach may be warranted in special situations, such as immunocompromised travelers.

Malaria in Peru: prophylaxis is recommended for all areas below 2000 m (6561 ft), including the cities of Iquitos and Puerto Maldonado, with the exception of the cities of Ica, Lima, the coast south of Lima, and Nazca. Most cases occur in Loreto (see Emerging Infectious Diseases), where malaria transmission has reached epidemic levels. There is no malaria risk in the highland tourist areas (Cuzco, Machu Picchu, and Lake Titicaca) and the southern cities of Arequipa, Moquegua, Puno, and Tacna. For a map showing the risk of malaria in different parts of the country, go to the Pan American Health Organization.

Either mefloquine (Lariam), atovaquone/proguanil (Malarone)(PDF), or doxycycline may be given. Mefloquine is taken once weekly in a dosage of 250 mg, starting one-to-two weeks before arrival and continuing through the trip and for four weeks after departure. Mefloquine may cause mild neuropsychiatric symptoms, including nausea, vomiting, dizziness, insomnia, and nightmares. Rarely, severe reactions occur, including depression, anxiety, psychosis, hallucinations, and seizures. Mefloquine should not be given to anyone with a history of seizures, psychiatric illness, cardiac conduction disorders, or allergy to quinine or quinidine. Those taking mefloquine (Lariam) should read the Lariam Medication Guide (PDF). Atovaquone/proguanil (Malarone) is a combination pill taken once daily with food starting two days before arrival and continuing through the trip and for seven days after departure. Side-effects, which are typically mild, may include abdominal pain, nausea, vomiting, headache, diarrhea, or dizziness. Serious adverse reactions are rare. Doxycycline is effective, but may cause an exaggerated sunburn reaction, which limits its usefulness in the tropics.

Insect protection measures are essential in all areas where malaria is reported.

Long-term travelers who may not have access to medical care should bring along medications for emergency self-treatment should they develop symptoms suggestive of malaria, such as fever, chills, headaches, and muscle aches, and cannot obtain medical care within 24 hours. See malaria for details. Symptoms of malaria sometimes do not occur for months or even years after exposure.

The number of cases of malaria has risen sharply in recent years, due in part to internal migration and the spread of irrigation for rice and cotton farming.

For further information about malaria in Peru, including a map showing the risk of malaria in different parts of the country, go to the World Health Organization.

Altitude sickness may occur in travelers who ascend rapidly to altitudes greater than 2500 meters, including Cusco (3000 meters) and Lake Titicaca (4000 meters). Acetazolamide is the drug of choice to prevent altitude sickness. The usual dosage is 125 or 250 mg twice daily starting 24 hours before ascent and continuing for 48 hours after arrival at altitude. Possible side-effects include increased urinary volume, numbness, tingling, nausea, drowsiness, myopia and temporary impotence. Acetazolamide should not be given to pregnant women or those with a history of sulfa allergy. For those who cannot tolerate acetazolamide, the preferred alternative is dexamethasone 4 mg taken four times daily. Unlike acetazolamide, dexamethasone must be tapered gradually upon arrival at altitude, since there is a risk that altitude sickness will occur as the dosage is reduced.

Travel to high altitudes is generally not recommended for those with a history of heart disease, lung disease, or sickle cell disease.

Revisions

<categorytext name="Medications">
 
 Medications
 
 
 <a href="/mdtravelhealth/resource/travelers_diarrhea">Travelers' diarrhea</a> is the most common travel-related ailment. The cornerstone of prevention is food and water precautions, as outlined below. All travelers should bring along an antibiotic and an antidiarrheal drug to be started promptly if significant diarrhea occurs, defined as three or more loose stools in an 8-hour period or five or more loose stools in a 24-hour period, especially if associated with nausea, vomiting, cramps, fever or blood in the stool. A quinolone antibiotic is usually prescribed: either ciprofloxacin (Cipro) 500 mg twice daily or levofloxacin (Levaquin) 500 mg once daily for a total of three days. Quinolones are generally well-tolerated, but occasionally cause sun sensitivity and should not be given to children, pregnant women, or anyone with a history of quinolone allergy. Alternative regimens include a three day course of <a href="http://www.salix.com/pdf/XifaxanPI.pdf">rifaximin (Xifaxan)</a> 200 mg three times daily or <a href="http://www.pfizer.com/hml/pi's/zithromaxregpi.html">azithromycin (Zithromax)</a> 500 mg once daily. Rifaximin should not be used by those with fever or bloody stools and is not approved for pregnant women or those under age 12. Azithromycin should be avoided in those allergic to erythromycin or related antibiotics. An antidiarrheal drug such as loperamide (Imodium) or diphenoxylate (Lomotil) should be taken as needed to slow the frequency of stools, but not enough to stop the bowel movements completely. Diphenoxylate (Lomotil) and loperamide (Imodium) should not be given to children under age two. 
 Most cases of travelers' diarrhea are mild and do not require either antibiotics or antidiarrheal drugs. Adequate fluid intake is essential. 
 If diarrhea is severe or bloody, or if fever occurs with shaking chills, or if abdominal pain becomes marked, or if diarrhea persists for more than 72 hours, medical attention should be sought. 
 Though effective, antibiotics are not recommended prophylactically (i.e. to prevent diarrhea before it occurs) because of the risk of adverse effects, though this approach may be warranted in special situations, such as immunocompromised travelers. 
 
 <a href="/mdtravelhealth/resource/malaria">Malaria</a> in Peru: prophylaxis is recommended for all areas below 2000 m (6561 ft), including the cities of Iquitos and Puerto Maldonado, with the exception of the cities of Ica, Lima, the coast south of Lima, and Nazca. Most cases occur in Loreto (see Emerging Infectious Diseases), where malaria transmission has reached epidemic levels. There is no malaria risk in the highland tourist areas (Cuzco, Machu Picchu, and Lake Titicaca) and the southern cities of Arequipa, Moquegua, Puno, and Tacna. For a map showing the risk of malaria in different parts of the country, go to the <a href="http://www.paho.org/English/HCP/HCT/MAL/maps-cartagena.htm">Pan American Health Organization</a>.
 Either mefloquine (Lariam), <a href="http://us.gsk.com/products/assets/us_malarone.pdf">atovaquone/proguanil (Malarone)(PDF)</a>, or doxycycline may be given. Mefloquine is taken once weekly in a dosage of 250 mg, starting one-to-two weeks before arrival and continuing through the trip and for four weeks after departure. Mefloquine may cause mild neuropsychiatric symptoms, including nausea, vomiting, dizziness, insomnia, and nightmares. Rarely, severe reactions occur, including depression, anxiety, psychosis, hallucinations, and seizures. Mefloquine should not be given to anyone with a history of seizures, psychiatric illness, cardiac conduction disorders, or allergy to quinine or quinidine. Those taking mefloquine (Lariam) should read the Lariam Medication Guide (PDF). Atovaquone/proguanil (Malarone) is a combination pill taken once daily with food starting two days before arrival and continuing through the trip and for seven days after departure. Side-effects, which are typically mild, may include abdominal pain, nausea, vomiting, headache, diarrhea, or dizziness. Serious adverse reactions are rare. Doxycycline is effective, but may cause an exaggerated sunburn reaction, which limits its usefulness in the tropics.
 
 Insect protection measures are essential in all areas where malaria is reported.
 Long-term travelers who may not have access to medical care should bring along medications for emergency self-treatment should they develop symptoms suggestive of malaria, such as fever, chills, headaches, and muscle aches, and cannot obtain medical care within 24 hours. See <a href="/mdtravelhealth/resource/malaria">malaria</a> for details. Symptoms of malaria sometimes do not occur for months or even years after exposure.
 The number of cases of malaria has risen sharply in recent years, due in part to internal migration and the spread of irrigation for rice and cotton farming. 
 For further information about malaria in Peru, including a map showing the risk of malaria in different parts of the country, go to the World Health Organization.
 
 <a href="/mdtravelhealth/resource/altitude_sickness">Altitude sickness</a> may occur in travelers who ascend rapidly to altitudes greater than 2500 meters, including Cusco (3000 meters) and Lake Titicaca (4000 meters). Acetazolamide is the drug of choice to prevent altitude sickness. The usual dosage is 125 or 250 mg twice daily starting 24 hours before ascent and continuing for 48 hours after arrival at altitude. Possible side-effects include increased urinary volume, numbness, tingling, nausea, drowsiness, myopia and temporary impotence. Acetazolamide should not be given to pregnant women or those with a history of sulfa allergy. For those who cannot tolerate acetazolamide, the preferred alternative is dexamethasone 4 mg taken four times daily. Unlike acetazolamide, dexamethasone must be tapered gradually upon arrival at altitude, since there is a risk that altitude sickness will occur as the dosage is reduced. 
 Travel to high altitudes is generally not recommended for those with a history of heart disease, lung disease, or sickle cell disease.
</categorytext>

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Immunizations You can't Edit

3

Immunizations

The following are the recommended vaccinations for Peru.

Hepatitis A vaccine is recommended for all travelers over one year of age. It should be given at least two weeks (preferably four weeks or more) before departure. A booster should be given 6-12 months later to confer long-term immunity. Two vaccines are currently available: VAQTA (Merck and Co., Inc.) and HAVRIX (GlaxoSmithKline). Both are well-tolerated. Side-effects, which are generally mild, may include soreness at the injection site, headache, and malaise.

Older adults, immunocompromised persons, and those with chronic liver disease or other chronic medical conditions who have less than two weeks before departure should receive a single intramuscular dose of immune globulin (0.02 mL/kg) at a separate anatomic injection site in addition to the initial dose of vaccine. Travelers who are less than one year of age or allergic to a vaccine component should receive a single intramuscular dose of immune globulin (see hepatitis A for dosage) in the place of vaccine.

Typhoid vaccine is recommended for all travelers. It is generally given in an oral form (Vivotif Berna) consisting of four capsules taken on alternate days until completed. The capsules should be kept refrigerated and taken with cool liquid. Side-effects are uncommon and may include abdominal discomfort, nausea, rash or hives. The alternative is an injectable polysaccharide vaccine (Typhim Vi; Aventis Pasteur Inc.) (PDF), given as a single dose. Adverse reactions, which are uncommon, may include discomfort at the injection site, fever and headache. The oral vaccine is approved for travelers at least six years old, whereas the injectable vaccine is approved for those over age two. There are no data concerning the safety of typhoid vaccine during pregnancy. The injectable vaccine (Typhim Vi) is probably preferable to the oral vaccine in pregnant and immunocompromised travelers.

Yellow fever vaccine is recommended for all travelers greater than nine months of age going to the following areas less than 2300 m in elevation: the entire regions of Amazonas, Loreto, Madre de Dios, San Martin, and Ucayali and designated areas (see map) of the following regions: far northeastern Ancash; northern Apurimac; northern and northeastern Ayacucho; northern and eastern Cajamarca; northwestern, northern, and northeastern Cusco; far northern Huancavelica; northern, central, and eastern Huanuco; northern and eastern Junin; eastern La Libertad; central and eastern Pasco; eastern Piura; and northern Puno. The vaccine should be considered only for those at increased risk due to prolonged travel, heavy exposure to mosquitoes, or inability to avoid mosquito bites, for travel to the following areas west of the Andes: the entire regions of Lambayeque and Tumbes and the designated areas of west-central Cajamarca and western Piura (see map). The vaccine is not recommended for travelers whose itineraries are limited to the following areas: all areas greater than 2300 m in elevation, areas west of the Andes not listed above, the cities of Cuzco and Lima, Machu Picchu, and the Inca Trail (see map). In recent years, yellow fever has been reported from the departments of Amazonas, Ancash, Ayacucho, Cusco, Huanuco, Junin, Loreto, Madre de Dios, Metas, Pasco, Puno, San Martin, and Ucayali (see "Recent outbreaks" below.).

Yellow fever vaccine (YF-VAX; Aventis Pasteur Inc.) (PDF) must be administered at an approved yellow fever vaccination center, which will give each vaccinee a fully validated International Certificate of Vaccination. Reactions to the vaccine, which are generally mild, include headaches, muscle aches, and low-grade fevers. Yellow fever vaccine should not in general be given to those who are younger than nine months of age, pregnant, immunocompromised, or allergic to eggs. It should also not be given to those with a history of thymus disease or thymectomy. Serious allergic reactions, such as hives or asthma, are rare and generally occur in those with a history of egg allergy.

Hepatitis B vaccine is recommended for all travelers if not previously vaccinated. Two vaccines are currently licensed in the United States: Recombivax HB (Merck and Co., Inc.) and Engerix-B (GlaxoSmithKline) (PDF). A full series consists of three intramuscular doses given at 0, 1 and 6 months. Engerix-B is also approved for administration at 0, 1, 2, and 12 months, which may be appropriate for travelers departing in less than 6 months. Side-effects are generally mild and may include discomfort at the injection site and low-grade fever. Severe allergic reactions (anaphylaxis) occur rarely.

Rabies vaccine is recommended for travelers spending a lot of time outdoors, for travelers at high risk for animal bites, such as veterinarians and animal handlers, for long-term travelers and expatriates, and for travelers involved in any activities that might bring them into direct contact with bats. Children are considered at higher risk because they tend to play with animals, may receive more severe bites, or may not report bites. In Peru, most cases are related to contact with dogs or vampire bats. A complete preexposure series consists of three doses of vaccine injected into the deltoid muscle on days 0, 7, and 21 or 28. Side-effects may include pain at the injection site, headache, nausea, abdominal pain, muscle aches, dizziness, or allergic reactions.

Any animal bite or scratch should be thoroughly cleaned with large amounts of soap and water and local health authorities should be contacted immediately for possible post-exposure treatment, whether or not the person has been immunized against rabies.

Tetanus-diphtheria vaccine is recommended for all travelers who have not received a tetanus-diphtheria immunization within the last 10 years.

Measles-mumps-rubella vaccine: two doses are recommended (if not previously given) for all travelers born after 1956, unless blood tests show immunity. Many adults born after 1956 and before 1970 received only one vaccination against measles, mumps, and rubella as children and should be given a second dose before travel. MMR vaccine should not be given to pregnant or severely immunocompromised individuals.

Cholera vaccine is not generally recommended. Cholera continues to occur in Peru, but the number of cases has fallen dramatically in recent years. Most travelers are at extremely low risk for infection. Two oral vaccines have recently been developed: Orochol (Mutacol), licensed in Canada and Australia, and Dukoral, licensed in Canada, Australia, and the European Union. These vaccines, where available, are recommended only for high-risk individuals, such as relief workers, health professionals, and those traveling to remote areas where cholera epidemics are occurring and there is limited access to medical care. The only cholera vaccine approved for use in the United States is no longer manufactured or sold, due to low efficacy and frequent side-effects.

The number of cholera cases increased sharply in early 1998, probably as a result of storms and floods caused by El Nino.

Polio vaccine is not recommended for any adult traveler who completed the recommended childhood immunizations. Polio has been eradicated from the Americas, except for a small outbreak of vaccine-related poliomyelitis in the Dominican Republic and Haiti in late 2000.

Revisions

<categorytext name="Immunizations">
 
 Immunizations
 
 The following are the recommended vaccinations for Peru.
 
 <a href="/mdtravelhealth/resource/hepatitis_a">Hepatitis A</a> vaccine is recommended for all travelers over one year of age. It should be given at least two weeks (preferably four weeks or more) before departure. A booster should be given 6-12 months later to confer long-term immunity. Two vaccines are currently available: VAQTA (Merck and Co., Inc.) and HAVRIX (GlaxoSmithKline). Both are well-tolerated. Side-effects, which are generally mild, may include soreness at the injection site, headache, and malaise.
 Older adults, immunocompromised persons, and those with chronic liver disease or other chronic medical conditions who have less than two weeks before departure should receive a single intramuscular dose of immune globulin (0.02 mL/kg) at a separate anatomic injection site in addition to the initial dose of vaccine. Travelers who are less than one year of age or allergic to a vaccine component should receive a single intramuscular dose of immune globulin (see <a href="/mdtravelhealth/resource/hepatitis_a">hepatitis A</a> for dosage) in the place of vaccine.
 
 <a href="/mdtravelhealth/resource/typhoid_fever">Typhoid</a> vaccine is recommended for all travelers. It is generally given in an oral form (Vivotif Berna) consisting of four capsules taken on alternate days until completed. The capsules should be kept refrigerated and taken with cool liquid. Side-effects are uncommon and may include abdominal discomfort, nausea, rash or hives. The alternative is an injectable polysaccharide vaccine (Typhim Vi; Aventis Pasteur Inc.) (PDF), given as a single dose. Adverse reactions, which are uncommon, may include discomfort at the injection site, fever and headache. The oral vaccine is approved for travelers at least six years old, whereas the injectable vaccine is approved for those over age two. There are no data concerning the safety of typhoid vaccine during pregnancy. The injectable vaccine (Typhim Vi) is probably preferable to the oral vaccine in pregnant and immunocompromised travelers.
 
 <a href="/mdtravelhealth/resource/yellow_fever">Yellow fever</a> vaccine is recommended for all travelers greater than nine months of age going to the following areas less than 2300 m in elevation: the entire regions of Amazonas, Loreto, Madre de Dios, San Martin, and Ucayali and designated areas (see <a href="http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-3-infectious-diseases-related-to-travel/yellow-fever.htm#2854">map</a>) of the following regions: far northeastern Ancash; northern Apurimac; northern and northeastern Ayacucho; northern and eastern Cajamarca; northwestern, northern, and northeastern Cusco; far northern Huancavelica; northern, central, and eastern Huanuco; northern and eastern Junin; eastern La Libertad; central and eastern Pasco; eastern Piura; and northern Puno. The vaccine should be considered only for those at increased risk due to prolonged travel, heavy exposure to mosquitoes, or inability to avoid mosquito bites, for travel to the following areas west of the Andes: the entire regions of Lambayeque and Tumbes and the designated areas of west-central Cajamarca and western Piura (see <a href="http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-3-infectious-diseases-related-to-travel/yellow-fever.htm#2854">map</a>). The vaccine is not recommended for travelers whose itineraries are limited to the following areas: all areas greater than 2300 m in elevation, areas west of the Andes not listed above, the cities of Cuzco and Lima, Machu Picchu, and the Inca Trail (see <a href="http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-3-infectious-diseases-related-to-travel/yellow-fever.htm#2854">map</a>). In recent years, yellow fever has been reported from the departments of Amazonas, Ancash, Ayacucho, Cusco, Huanuco, Junin, Loreto, Madre de Dios, Metas, Pasco, Puno, San Martin, and Ucayali (see "Recent outbreaks" below.).
 Yellow fever vaccine (YF-VAX; Aventis Pasteur Inc.) (PDF) must be administered at an approved yellow fever vaccination center, which will give each vaccinee a fully validated International Certificate of Vaccination. Reactions to the vaccine, which are generally mild, include headaches, muscle aches, and low-grade fevers. Yellow fever vaccine should not in general be given to those who are younger than nine months of age, pregnant, immunocompromised, or allergic to eggs. It should also not be given to those with a history of thymus disease or thymectomy. Serious allergic reactions, such as hives or asthma, are rare and generally occur in those with a history of egg allergy.
 
 <a href="/mdtravelhealth/resource/hepatitis_b">Hepatitis B</a> vaccine is recommended for all travelers if not previously vaccinated. Two vaccines are currently licensed in the United States: Recombivax HB (Merck and Co., Inc.) and <a href="http://us.gsk.com/products/assets/us_engerixb.pdf">Engerix-B (GlaxoSmithKline) (PDF)</a>. A full series consists of three intramuscular doses given at 0, 1 and 6 months. Engerix-B is also approved for administration at 0, 1, 2, and 12 months, which may be appropriate for travelers departing in less than 6 months. Side-effects are generally mild and may include discomfort at the injection site and low-grade fever. Severe allergic reactions (anaphylaxis) occur rarely.
 
 <a href="/mdtravelhealth/resource/rabies">Rabies</a> vaccine is recommended for travelers spending a lot of time outdoors, for travelers at high risk for animal bites, such as veterinarians and animal handlers, for long-term travelers and expatriates, and for travelers involved in any activities that might bring them into direct contact with bats. Children are considered at higher risk because they tend to play with animals, may receive more severe bites, or may not report bites. In Peru, most cases are related to contact with dogs or vampire bats. A complete preexposure series consists of three doses of vaccine injected into the deltoid muscle on days 0, 7, and 21 or 28. Side-effects may include pain at the injection site, headache, nausea, abdominal pain, muscle aches, dizziness, or allergic reactions.
 
 Any animal bite or scratch should be thoroughly cleaned with large amounts of soap and water and local health authorities should be contacted immediately for possible post-exposure treatment, whether or not the person has been immunized against rabies.
 
 <a href="/mdtravelhealth/resource/tetanus">Tetanus</a>-<a href="/mdtravelhealth/resource/diphtheria">diphtheria</a> vaccine is recommended for all travelers who have not received a tetanus-diphtheria immunization within the last 10 years.
 
 <a href="/mdtravelhealth/resource/measles">Measles</a>-<a href="/mdtravelhealth/resource/mumps">mumps</a>-<a href="/mdtravelhealth/resource/rubella">rubella</a> vaccine: two doses are recommended (if not previously given) for all travelers born after 1956, unless blood tests show immunity. Many adults born after 1956 and before 1970 received only one vaccination against measles, mumps, and rubella as children and should be given a second dose before travel. MMR vaccine should not be given to pregnant or severely immunocompromised individuals.
 
 <a href="/mdtravelhealth/resource/cholera">Cholera</a> vaccine is not generally recommended. Cholera continues to occur in Peru, but the number of cases has fallen dramatically in recent years. Most travelers are at extremely low risk for infection. Two oral vaccines have recently been developed: Orochol (Mutacol), licensed in Canada and Australia, and <a href="http://www.medicines.org.uk/emc/medicine/26272/SPC/Dukoral+Oral+Cholera+Vaccine/">Dukoral</a>, licensed in Canada, Australia, and the European Union. These vaccines, where available, are recommended only for high-risk individuals, such as relief workers, health professionals, and those traveling to remote areas where cholera epidemics are occurring and there is limited access to medical care. The only cholera vaccine approved for use in the United States is no longer manufactured or sold, due to low efficacy and frequent side-effects.
 The number of cholera cases increased sharply in early 1998, probably as a result of storms and floods caused by El Nino.
 
 <a href="/mdtravelhealth/resource/polio">Polio</a> vaccine is not recommended for any adult traveler who completed the recommended childhood immunizations. Polio has been eradicated from the Americas, except for a small outbreak of vaccine-related poliomyelitis in the Dominican Republic and Haiti in late 2000.
</categorytext>

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Recent outbreaks of diseases You can't Edit

4

Recent outbreaks

An outbreak of leptospirosis was reported in April 2013 from the city of Juanjui, capital of the Mariscal Caceres Province, in the San Martin Region. In April 2012, a leptospirosis outbreak occurred in the Loreto Region after river water rose to its highest level in 25 years. More than 300 cases were described, three of them fatal. Leptospirosis is a bacterial infection transmitted to humans by exposure to water contaminated by the urine of infected animals. Symptoms may include fever, chills, headache, muscle aches, conjunctivitis (pink eye), photophobia (light sensitivity), and rash. Most cases resolve uneventfully, but a small number may be complicated by meningitis, kidney failure, liver failure, or hemorrhage. Those engaging in water activities may consider taking a prophylactic 200 mg dose of doxycycline, either once weekly or as a one-time dose. An increased number of cases of leptospirosis was also reported from Peru after flooding in 1998.

An outbreak of human rabies caused by vampire bats was reported in May 2012 from the La Convencion province, Cusco region, causing the deaths of seven Machiguengas [indigenous] children from Camana. In February 2011, a rabies outbreak related to vampire bats occurred in the San Ramon and Yupicusa native communities in Bagua province in the Amazonas region, near the border with Ecuador, about 1000 km north of Lima. Nine deaths were described by March. In August 2010, an outbreak of vampire bat-associated rabies occurred in the Awajun and Wampis indigenous communities situated about 600 miles north of the capital Lima, on the border with Ecuador in northeastern Peru, causing 20 deaths as of September. In January 2007, an outbreak of vampire bat-transmitted rabies occurred in the departments of Madre de Dios and Puno in the southeastern part of the country, causing 23 fatalities as of March. Between September and November 2006, two outbreaks of human rabies caused by vampire bats were reported from Condorcanqui Province, near the border with Ecuador in the northern part of Peru, killing 11 children. Vampire bats are about the size of a human thumb and inhabit caves and the hollows of tree trunks. They are abundant in these parts of South America. Travelers should not sleep in open areas without mosquito netting. Also, rabies vaccine should be considered for all travelers to the Amazonas and the Cusco regions. See ProMED-mail (January 23 and 31 and March 6, 2007; August 14, 2010; and February 19, 2011) for further information.

Cases of yellow fever are reported each year from Peru. The virus is endemic in the Amazon basin. A total of 31 cases, eight of them fatal, were reported for the year 2013. In March 2013, a fatal case was reported from Sandia province between Phara and Limbani. In March 2012, a fatal case occurred in the Ayacucho region. In February 2012, three fatal cases were reported from the Puno region. In Peru, most cases of yellow fever occur among males over the age of 15 who work in the countryside. Yellow fever vaccine is recommended for all those who will be visiting areas east of the Andes mountains. Yellow fever vaccine is not recommended for those visiting only Machu Picchu and the city of Cuzco, because the mosquitoes which transmit yellow fever are not present at high altitudes.

In January 2009, a confirmed case was reported from the department of San Martin. In the first 21 weeks of 2008, there were three confirmed cases, including one from the Amazonas Department and one from the San Martin Department, and 14 probable cases. All of the confirmed cases were fatal. In February 2007, three cases of yellow fever, all fatal, were reported from the province of La Convencion, a low-lying area in the northernmost part in the department of Cuzco. In March 2006, four cases were reported from Santa Rosa, San Martín and Palmapampa, in the jungle part of Ayacucho Department (see ProMED-mail). In the first six months of 2004, the government of Peru reported a total of 52 yellow fever cases, more than half of them fatal. Cases were identified in the districts of Echerate (1 case), in the Department of Cuzco; Cholón (1), Daniel Alomia Robles (1), Huánuco (1) and José Crespo y Castillo (5) in the Department of Huánuco; Junín, (1), Perené (4) and Pichanaqui (17), in the Department of Junín; Ramón Castilla (1) in the Department of Loreto; Huepétuhe (5), Laberinto (1) and Manú (1) in the Department of Madre de Dios; Campanilla (7), La Banda de Shiclayo (1), Moyobamba (3), and Nueva Cajamarca (2), in the Department of San Martín. For further information, go to the Pan-American Health Organization.

In July 2003, a yellow fever outbreak was reported from the town of Pavo, Province of Bella Vista, and from the towns of Aucarca and El Zancudo, both located in the Province of Mariscal Caceres. See the Pan-American Health Organization for further information. In June 2001, an outbreak was reported from the Department of Loreto, in the Peruvian Amazon Region, in the districts of Puinahua, San Pablo and Iquitos. See the World Health Organization for details. Yellow fever reached epidemic proportions in 1995, mainly affecting farmers of Andean origin who lived in the central jungles. The outbreak was related to increases in internal migration and the development of new farming and industrial areas, and was terminated by renewed vaccination efforts. For further details on yellow fever in Peru, go to the Pan-American Health Organization (PDF)

An outbreak of bartonellosis, a bacterial infection transmitted by sandflies, was reported from the Huancabamba Province, Piura Region, in October 2011, causing a total of 74 cases. Of these, there were 33 acute cases (Oroya fever) and 41 cases of verruga peruana (Peruvian wart). Two of the cases were fatal. In September 2006, a small outbreak of Oroya fever was reported from Collo Locality, Arahuay District, Canta Province, approximately 80 km from Lima (see ProMED-mail; September 28, 2006, and October 12, 2011). Historically, transmission has been limited to arid river valleys on the western slopes of the Andes between 800 and 3000 meters, but the recent report from Collo locality indicates that the range may be expanding. Bartonellosis may cause either an acute febrile illness, often associated with anemia, or a chronic disfiguring skin lesion known as "Peruvian wart". A major outbreak was reported from Peru in 2004, resulting in more than 7000 cases. There is no vaccine for bartonellosis. Insect protection measures are strongly advised, as below.

An outbreak of dengue fever caused by a particularly aggressive strain of the virus was reported in January 2011 from Iquitos and Loreto province in the northern Amazon jungle region, causing almost 13,000 cases and 14 deaths by February. In February 2011, a dengue outbreak was reported from Madre de Dios. Cases of dengue fever, a flu-like illness sometimes complicated by hemorrhage or shock, are reported annually from Peru, chiefly from the northern coast and the northeastern and central jungle region. Dengue has also been reported near the Ecuadoran border. Dengue fever is transmitted by Aedes mosquitoes, which bite primarily in the daytime and favor densely populated areas, though they also inhabit rural environments. No vaccine is available at this time. Insect protection measures are essential, as below.

In April 2010, a dengue outbreak occurred in Piura, in the far northwesternn part of the country. A dengue outbreak was reported in the first two months of 2009 from the Tumbes region in northwest Peru, resulting in approximately 5000 suspected cases. In February 2009, an outbreak was reported from the forested region of Ucayali, on the border with Brazil. In October 2008, a dengue outbreak was reported from the Iquitos district in the state of Loreto. An outbreak was also reported from Loreto in January 2008, chiefly involving the Iquitos, San Juan Bautista, and Punchana districts. In February 2008, outbreaks were reported from La Libertad, 550 km north of Lima, and Ucayali. For the country as a whole, a total of 6907 dengue cases, including two deaths, were reported for the year 2007, and a total of 5531 cases, none fatal, were recorded for 2006.

An outbreak of human rabies caused by vampire bats was reported in May 2012 from the La Convencion province, Cusco region, causing the deaths of seven Machiguengas [indigenous] children from Camana. In February 2011, a rabies outbreak related to vampire bats occurred in the San Ramon and Yupicusa native communities in Bagua province in the Amazonas region, near the border with Ecuador, about 1000 km north of Lima. Nine deaths were described by March. In August 2010, an outbreak of vampire bat-associated rabies occurred in the Awajun and Wampis indigenous communities situated about 600 miles north of the capital Lima, on the border with Ecuador in northeastern Peru, causing 20 deaths as of September. In January 2007, an outbreak of vampire bat-transmitted rabies occurred in the departments of Madre de Dios and Puno in the southeastern part of the country, causing 23 fatalities as of March. Between September and November 2006, two outbreaks of human rabies caused by vampire bats were reported from Condorcanqui Province, near the border with Ecuador in the northern part of Peru, killing 11 children. Vampire bats are about the size of a human thumb and inhabit caves and the hollows of tree trunks. They are abundant in these parts of South America. Travelers should not sleep in open areas without mosquito netting. Also, rabies vaccine should be considered for all travelers to the Amazonas region. See ProMED-mail (January 23 and 31 and March 6, 2007; August 14, 2010; and February 19, 2011) for further information.

An outbreak of plague was reported in July 2010 from the provinces of Ascope and Trujillo, department La Libertad. As of August, a total of 27 human cases had been identified: 21 bubonic (including one fatality), four pneumonic, and two septicemic (both fatal). Of the 27 cases, 25 acquired the infection in the Ascope and two in Trujillo. The last plague outbreak reported in the province of Ascope occurred in the locality of Santa Clara, in the district of Casa Grande between August and September 2009 (see ProMED-mail, August 5, 2010). A total of 15 cases were reported, nine of which were confirmed.

Human plague is reported from Peru nearly every year, chiefly from the departments of Cajamarca, La Libertad, Piura, and Lambayeque in the northern part of the country. The plague is usually transmitted by the bite of rodent fleas. Less commonly, the disease is acquired by inhalation of infected droplets, which may be coughed into the air by a person with plague pneumonia, or by direct exposure to infected blood or tissues. Most travelers are at low risk for the plague. Those who may have contact with rodents or their fleas should bring along a bottle of doxycycline, to be taken prophylactically if exposure occurs. Those less than eight years of age or allergic to doxycycline may take trimethoprim-sulfamethoxazole instead. To minimize risk, travelers should avoid areas containing rodent burrows or nests, never handle sick or dead animals, and follow insect protection measures, as described below.

An outbreak of Oropouche fever was reported in June 2010 from the Bagazan community, Pachiza district, in the department of San Martin, causing more than 160 cases. The virus is transmitted by the bite of a hematophagous (blood-sucking) midge named Culicoides paraensis. Symptoms may include fever, headache, loss of appetite, muscle aches, joint pains, and vomiting. Aseptic meningitis is a rare complication.

Revisions

<categorytext name="Recentoutbreaks">
 
 Recent outbreaks
 
 An outbreak of <a href="/mdtravelhealth/resource/leptospirosis">leptospirosis</a> was reported in April 2013 from the city of Juanjui, capital of the Mariscal Caceres Province, in the San Martin Region. In April 2012, a leptospirosis outbreak occurred in the Loreto Region after river water rose to its highest level in 25 years. More than 300 cases were described, three of them fatal. Leptospirosis is a bacterial infection transmitted to humans by exposure to water contaminated by the urine of infected animals. Symptoms may include fever, chills, headache, muscle aches, conjunctivitis (pink eye), photophobia (light sensitivity), and rash. Most cases resolve uneventfully, but a small number may be complicated by meningitis, kidney failure, liver failure, or hemorrhage. Those engaging in water activities may consider taking a prophylactic 200 mg dose of doxycycline, either once weekly or as a one-time dose. An increased number of cases of leptospirosis was also reported from Peru after flooding in 1998. 
 An outbreak of <a href="/mdtravelhealth/resource/rabies">human rabies</a> caused by vampire bats was reported in May 2012 from the La Convencion province, Cusco region, causing the deaths of seven Machiguengas [indigenous] children from Camana. In February 2011, a rabies outbreak related to vampire bats occurred in the San Ramon and Yupicusa native communities in Bagua province in the Amazonas region, near the border with Ecuador, about 1000 km north of Lima. Nine deaths were described by March. In August 2010, an outbreak of vampire bat-associated rabies occurred in the Awajun and Wampis indigenous communities situated about 600 miles north of the capital Lima, on the border with Ecuador in northeastern Peru, causing 20 deaths as of September. In January 2007, an outbreak of vampire bat-transmitted rabies occurred in the departments of Madre de Dios and Puno in the southeastern part of the country, causing 23 fatalities as of March. Between September and November 2006, two outbreaks of human rabies caused by vampire bats were reported from Condorcanqui Province, near the border with Ecuador in the northern part of Peru, killing 11 children. Vampire bats are about the size of a human thumb and inhabit caves and the hollows of tree trunks. They are abundant in these parts of South America. Travelers should not sleep in open areas without mosquito netting. Also, rabies vaccine should be considered for all travelers to the Amazonas and the Cusco regions. See <a href="http://www.promedmail.org">ProMED-mail</a> (January 23 and 31 and March 6, 2007; August 14, 2010; and February 19, 2011) for further information.
 Cases of <a href="/mdtravelhealth/resource/yellow_fever">yellow fever</a> are reported each year from Peru. The virus is endemic in the Amazon basin. A total of 31 cases, eight of them fatal, were reported for the year 2013. In March 2013, a fatal case was reported from Sandia province between Phara and Limbani. In March 2012, a fatal case occurred in the Ayacucho region. In February 2012, three fatal cases were reported from the Puno region. In Peru, most cases of yellow fever occur among males over the age of 15 who work in the countryside. Yellow fever vaccine is recommended for all those who will be visiting areas east of the Andes mountains. Yellow fever vaccine is not recommended for those visiting only Machu Picchu and the city of Cuzco, because the mosquitoes which transmit yellow fever are not present at high altitudes. 
 In January 2009, a confirmed case was reported from the department of San Martin. In the first 21 weeks of 2008, there were three confirmed cases, including one from the Amazonas Department and one from the San Martin Department, and 14 probable cases. All of the confirmed cases were fatal. In February 2007, three cases of yellow fever, all fatal, were reported from the province of La Convencion, a low-lying area in the northernmost part in the department of Cuzco. In March 2006, four cases were reported from Santa Rosa, San Martín and Palmapampa, in the jungle part of Ayacucho Department (see <a href="http://www.promedmail.org">ProMED-mail</a>). In the first six months of 2004, the government of Peru reported a total of 52 yellow fever cases, more than half of them fatal. Cases were identified in the districts of Echerate (1 case), in the Department of Cuzco; Cholón (1), Daniel Alomia Robles (1), Huánuco (1) and José Crespo y Castillo (5) in the Department of Huánuco; Junín, (1), Perené (4) and Pichanaqui (17), in the Department of Junín; Ramón Castilla (1) in the Department of Loreto; Huepétuhe (5), Laberinto (1) and Manú (1) in the Department of Madre de Dios; Campanilla (7), La Banda de Shiclayo (1), Moyobamba (3), and Nueva Cajamarca (2), in the Department of San Martín. For further information, go to the <a href="http://www.paho.org/English/AD/DPC/CD/eid-eer-24-jun-2004.htm">Pan-American Health Organization</a>.
 In July 2003, a yellow fever outbreak was reported from the town of Pavo, Province of Bella Vista, and from the towns of Aucarca and El Zancudo, both located in the Province of Mariscal Caceres. See the <a href="http://www.paho.org/English/AD/DPC/CD/eid-eer-14-aug-2003.htm">Pan-American Health Organization</a> for further information. In June 2001, an outbreak was reported from the Department of Loreto, in the Peruvian Amazon Region, in the districts of Puinahua, San Pablo and Iquitos. See the World Health Organization for details. Yellow fever reached epidemic proportions in 1995, mainly affecting farmers of Andean origin who lived in the central jungles. The outbreak was related to increases in internal migration and the development of new farming and industrial areas, and was terminated by renewed vaccination efforts. For further details on yellow fever in Peru, go to the <a href="http://www.paho.org/English/HVP/HVI/2002_09_%2010_dc.pdf">Pan-American Health Organization (PDF)</a>
 An outbreak of bartonellosis, a bacterial infection transmitted by sandflies, was reported from the Huancabamba Province, Piura Region, in October 2011, causing a total of 74 cases. Of these, there were 33 acute cases (Oroya fever) and 41 cases of verruga peruana (Peruvian wart). Two of the cases were fatal. In September 2006, a small outbreak of Oroya fever was reported from Collo Locality, Arahuay District, Canta Province, approximately 80 km from Lima (see <a href="http://www.promedmail.org">ProMED-mail</a>; September 28, 2006, and October 12, 2011). Historically, transmission has been limited to arid river valleys on the western slopes of the Andes between 800 and 3000 meters, but the recent report from Collo locality indicates that the range may be expanding. Bartonellosis may cause either an acute febrile illness, often associated with anemia, or a chronic disfiguring skin lesion known as "Peruvian wart". A major outbreak was reported from Peru in 2004, resulting in more than 7000 cases. There is no vaccine for bartonellosis. Insect protection measures are strongly advised, as below.
 An outbreak of <a href="/mdtravelhealth/resource/dengue_fever">dengue fever</a> caused by a particularly aggressive strain of the virus was reported in January 2011 from Iquitos and Loreto province in the northern Amazon jungle region, causing almost 13,000 cases and 14 deaths by February. In February 2011, a dengue outbreak was reported from Madre de Dios. Cases of dengue fever, a flu-like illness sometimes complicated by hemorrhage or shock, are reported annually from Peru, chiefly from the northern coast and the northeastern and central jungle region. Dengue has also been reported near the Ecuadoran border. Dengue fever is transmitted by Aedes mosquitoes, which bite primarily in the daytime and favor densely populated areas, though they also inhabit rural environments. No vaccine is available at this time. Insect protection measures are essential, as below.
 In April 2010, a dengue outbreak occurred in Piura, in the far northwesternn part of the country. A dengue outbreak was reported in the first two months of 2009 from the Tumbes region in northwest Peru, resulting in approximately 5000 suspected cases. In February 2009, an outbreak was reported from the forested region of Ucayali, on the border with Brazil. In October 2008, a dengue outbreak was reported from the Iquitos district in the state of Loreto. An outbreak was also reported from Loreto in January 2008, chiefly involving the Iquitos, San Juan Bautista, and Punchana districts. In February 2008, outbreaks were reported from La Libertad, 550 km north of Lima, and Ucayali. For the country as a whole, a total of 6907 dengue cases, including two deaths, were reported for the year 2007, and a total of 5531 cases, none fatal, were recorded for 2006. 
 An outbreak of <a href="/mdtravelhealth/resource/rabies">human rabies</a> caused by vampire bats was reported in May 2012 from the La Convencion province, Cusco region, causing the deaths of seven Machiguengas [indigenous] children from Camana. In February 2011, a rabies outbreak related to vampire bats occurred in the San Ramon and Yupicusa native communities in Bagua province in the Amazonas region, near the border with Ecuador, about 1000 km north of Lima. Nine deaths were described by March. In August 2010, an outbreak of vampire bat-associated rabies occurred in the Awajun and Wampis indigenous communities situated about 600 miles north of the capital Lima, on the border with Ecuador in northeastern Peru, causing 20 deaths as of September. In January 2007, an outbreak of vampire bat-transmitted rabies occurred in the departments of Madre de Dios and Puno in the southeastern part of the country, causing 23 fatalities as of March. Between September and November 2006, two outbreaks of human rabies caused by vampire bats were reported from Condorcanqui Province, near the border with Ecuador in the northern part of Peru, killing 11 children. Vampire bats are about the size of a human thumb and inhabit caves and the hollows of tree trunks. They are abundant in these parts of South America. Travelers should not sleep in open areas without mosquito netting. Also, rabies vaccine should be considered for all travelers to the Amazonas region. See <a href="http://www.promedmail.org">ProMED-mail</a> (January 23 and 31 and March 6, 2007; August 14, 2010; and February 19, 2011) for further information.
 An outbreak of <a href="/mdtravelhealth/resource/plague">plague</a> was reported in July 2010 from the provinces of Ascope and Trujillo, department La Libertad. As of August, a total of 27 human cases had been identified: 21 bubonic (including one fatality), four pneumonic, and two septicemic (both fatal). Of the 27 cases, 25 acquired the infection in the Ascope and two in Trujillo. The last plague outbreak reported in the province of Ascope occurred in the locality of Santa Clara, in the district of Casa Grande between August and September 2009 (see <a href="http://www.promedmail.org">ProMED-mail</a>, August 5, 2010). A total of 15 cases were reported, nine of which were confirmed. 
 Human plague is reported from Peru nearly every year, chiefly from the departments of Cajamarca, La Libertad, Piura, and Lambayeque in the northern part of the country. The plague is usually transmitted by the bite of rodent fleas. Less commonly, the disease is acquired by inhalation of infected droplets, which may be coughed into the air by a person with plague pneumonia, or by direct exposure to infected blood or tissues. Most travelers are at low risk for the plague. Those who may have contact with rodents or their fleas should bring along a bottle of doxycycline, to be taken prophylactically if exposure occurs. Those less than eight years of age or allergic to doxycycline may take trimethoprim-sulfamethoxazole instead. To minimize risk, travelers should avoid areas containing rodent burrows or nests, never handle sick or dead animals, and follow insect protection measures, as described below.
 An outbreak of Oropouche fever was reported in June 2010 from the Bagazan community, Pachiza district, in the department of San Martin, causing more than 160 cases. The virus is transmitted by the bite of a hematophagous (blood-sucking) midge named Culicoides paraensis. Symptoms may include fever, headache, loss of appetite, muscle aches, joint pains, and vomiting. Aseptic meningitis is a rare complication. 
</categorytext>

Edit Comment

Other Infections You can't Edit

5

Other infections

Gnathostomiasis, which is caused by a helminth known as Gnathostoma spinigerum, may be acquired by eating raw or undercooked freshwater fish, including ceviche, a popular lime-marinated fish salad. The chief symptom is intermittent, migratory swellings under the skin, sometimes associated with joint pains, muscle pains, or gastrointestinal symptoms. The symptoms may not begin until many months after exposure. See Moore et al. in Emerging Infectious Diseases for further information.

HIV (human immunodeficiency virus) infection is reported, but travelers are not at risk unless they have unprotected sexual contacts or receive injections or blood transfusions.

Other infections include

Chagas' disease (endemic in the southwestern region, including Arequipa, Moquegua, Tacna, and Ica Departments; the northwestern part of the country, including coastal regions from La Libertad, Lambayeque, Piura, and Tumbes Departments, and the northeastern region, including Amazonas, Cajamarca, and San Martin Departments; transmitted by triatomid insects found in substandard housing; see ProMED-mail, September 24, 2006)
Brucellosis (limited foci; most common animal source is infected cattle)
Histoplasmosis (reported in spelunkers returning from Mato Grosso)
Cutaneous and mucocutaneous leishmaniasis (chiefly from the mountain and jungle departments; cutaneous form seen mainly in children under age 15, due to increasing use of child labor for brush clearing and preparation of farmlands on mountain slopes of the Andes)
Anthrax (outbreaks reported from the region of Lambayeque in July 2006 and January 2008; from the Caudevilla locality, Supe District, in May 2008; and from La Libertad in March 2012; see ProMED-mail)
Louse-borne typhus (mountain areas)
Hantavirus infection (three cases reported from Iquitos, Loreto department, between July and September 2011; see ProMED-mail, July 21 and September 3, 2011; life-threatening viral infection; occurs in those who live in close association with rodents)
Venezuelan equine encephalitis (northern Peru)
Eastern equine encephalitis
Mayaro virus disease (transmitted by mosquitoes in tropical forests)
Echinococcus (mainly Andean region)
Cysticercosis
Fascioliasis (sheep-raising areas)
Cyclosporiasis (outbreak reported at naval base in Lima in 2006; see American Journal of Tropical Medicine and Hygiene)
Paragonimiasis (rare)

For in-depth public health information, go to the Pan-American Health Organization. For further information, go to the Ministerio de Salud (in Spanish).

Revisions

<categorytext name="OtherInfections">
 
 Other infections
 
 
 Gnathostomiasis, which is caused by a helminth known as Gnathostoma spinigerum, may be acquired by eating raw or undercooked freshwater fish, including ceviche, a popular lime-marinated fish salad. The chief symptom is intermittent, migratory swellings under the skin, sometimes associated with joint pains, muscle pains, or gastrointestinal symptoms. The symptoms may not begin until many months after exposure. See Moore et al. in Emerging Infectious Diseases for further information.
 
 HIV (human immunodeficiency virus) infection is reported, but travelers are not at risk unless they have unprotected sexual contacts or receive injections or blood transfusions.
 Other infections include
 <ul>
 <li>Chagas' disease (endemic in the southwestern region, including Arequipa, Moquegua, Tacna, and Ica Departments; the northwestern part of the country, including coastal regions from La Libertad, Lambayeque, Piura, and Tumbes Departments, and the northeastern region, including Amazonas, Cajamarca, and San Martin Departments; transmitted by triatomid insects found in substandard housing; see <a href="http://www.promedmail.org">ProMED-mail</a>, September 24, 2006)</li>
 <li>
 <a href="/mdtravelhealth/resource/brucellosis">Brucellosis</a> (limited foci; most common animal source is infected cattle)</li>
 <li>
 <a href="/mdtravelhealth/resource/histoplasmosis">Histoplasmosis</a> (reported in spelunkers returning from Mato Grosso)</li>
 <li>
 <a href="/mdtravelhealth/resource/leishmaniasis">Cutaneous and mucocutaneous leishmaniasis</a> (chiefly from the mountain and jungle departments; cutaneous form seen mainly in children under age 15, due to increasing use of child labor for brush clearing and preparation of farmlands on mountain slopes of the Andes)</li>
 <li>
 <a href="/mdtravelhealth/resource/anthrax">Anthrax</a> (outbreaks reported from the region of Lambayeque in July 2006 and January 2008; from the Caudevilla locality, Supe District, in May 2008; and from La Libertad in March 2012; see <a href="http://www.promedmail.org">ProMED-mail</a>)</li>
 <li>
 <a href="/mdtravelhealth/resource/typhus">Louse-borne typhus</a> (mountain areas) </li>
 <li>
 <a href="/mdtravelhealth/resource/hantavirus">Hantavirus infection</a> (three cases reported from Iquitos, Loreto department, between July and September 2011; see <a href="http://www.promedmail.org">ProMED-mail</a>, July 21 and September 3, 2011; life-threatening viral infection; occurs in those who live in close association with rodents)</li>
 <li>
 Venezuelan equine encephalitis (northern Peru)</li>
 <li>
 Eastern equine encephalitis
 </li>
 <li>
 Mayaro virus disease (transmitted by mosquitoes in tropical forests)</li>
 <li>
 Echinococcus (mainly Andean region)</li>
 <li>
 Cysticercosis
 </li>
 <li>
 Fascioliasis (sheep-raising areas)</li>
 <li>
 Cyclosporiasis (outbreak reported at naval base in Lima in 2006; see <a href="http://www.ajtmh.org/cgi/content/abstract/75/3/546?etoc">American Journal of Tropical Medicine and Hygiene</a>)</li>
 <li>
 Paragonimiasis (rare)</li>
 </ul>
 For in-depth public health information, go to the <a href="http://www.paho.org/English/DD/AIS/cp_604.htm">Pan-American Health Organization</a>. For further information, go to the Ministerio de Salud (in Spanish).
</categorytext>

Edit Comment

Food and Water You can't Edit

6

Food and water precautions

Do not drink tap water unless it has been boiled, filtered, or chemically disinfected. Do not drink unbottled beverages or drinks with ice. Do not eat fruits or vegetables unless they have been peeled or cooked. Avoid cooked foods that are no longer piping hot. Cooked foods that have been left at room temperature are particularly hazardous. Avoid unpasteurized milk and any products that might have been made from unpasteurized milk, such as ice cream. Avoid food and beverages obtained from street vendors. Do not eat raw or undercooked meat or fish, including ceviche. Some types of fish may contain poisonous biotoxins even when cooked. Barracuda in particular should never be eaten. Other fish that may contain toxins include red snapper, grouper, amberjack, and sea bass.

All travelers should bring along an antibiotic and an antidiarrheal drug to be started promptly if significant diarrhea occurs, defined as three or more loose stools in an 8-hour period or five or more loose stools in a 24-hour period, especially if accompanied by nausea, vomiting, cramps, fever or blood in the stool. Antibiotics which have been shown to be effective include ciprofloxacin (Cipro), levofloxacin (Levaquin), rifaximin (Xifaxan), or azithromycin (Zithromax). Either loperamide (Imodium) or diphenoxylate (Lomotil) should be taken in addition to the antibiotic to reduce diarrhea and prevent dehydration.

If diarrhea is severe or bloody, or if fever occurs with shaking chills, or if abdominal pain becomes marked, or if diarrhea persists for more than 72 hours, medical attention should be sought.

Revisions

<categorytext name="FoodandWater">
 
 Food and water precautions
 
 Do not drink tap water unless it has been <a href="/mdtravelhealth/resource/water_purification">boiled, filtered, or chemically disinfected</a>. Do not drink unbottled beverages or drinks with ice. Do not eat fruits or vegetables unless they have been peeled or cooked. Avoid cooked foods that are no longer piping hot. Cooked foods that have been left at room temperature are particularly hazardous. Avoid unpasteurized milk and any products that might have been made from unpasteurized milk, such as ice cream. Avoid food and beverages obtained from street vendors. Do not eat raw or undercooked meat or fish, including ceviche. Some types of fish may contain poisonous biotoxins even when cooked. Barracuda in particular should never be eaten. Other fish that may contain toxins include red snapper, grouper, amberjack, and sea bass.
 All travelers should bring along an antibiotic and an antidiarrheal drug to be started promptly if significant diarrhea occurs, defined as three or more loose stools in an 8-hour period or five or more loose stools in a 24-hour period, especially if accompanied by nausea, vomiting, cramps, fever or blood in the stool. Antibiotics which have been shown to be effective include <a href="http://www.univgraph.com/bayer/inserts/ciprotab.pdf">ciprofloxacin (Cipro)</a>, levofloxacin (Levaquin), <a href="http://www.salix.com/pdf/XifaxanPI.pdf">rifaximin (Xifaxan)</a>, or <a href="http://www.pfizer.com/hml/pi's/zithromaxregpi.html">azithromycin (Zithromax)</a>. Either loperamide (Imodium) or diphenoxylate (Lomotil) should be taken in addition to the antibiotic to reduce diarrhea and prevent dehydration. 
 If diarrhea is severe or bloody, or if fever occurs with shaking chills, or if abdominal pain becomes marked, or if diarrhea persists for more than 72 hours, medical attention should be sought. 
</categorytext>

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Insect Tick Protection You can't Edit

7

Insect and Tick Protection

Wear long sleeves, long pants, hats and shoes (rather than sandals). Apply insect repellents containing 25-50% DEET (N,N-diethyl-3-methylbenzamide) or 20% picaridin (Bayrepel) to exposed skin (but not to the eyes, mouth, or open wounds). DEET may also be applied to clothing. Products with a lower concentration of either repellent need to be repplied more frequently. Products with a higher concentration of DEET carry an increased risk of neurologic toxicity, especially in children, without any additional benefit. Do not use either DEET or picaridin on children less than two years of age. For additional protection, apply permethrin-containing compounds to clothing, shoes, and bed nets. Permethrin-treated clothing appears to have little toxicity. Don't sleep with the window open unless there is a screen. If sleeping outdoors or in an accommodation that allows entry of mosquitoes, use a bed net, preferably impregnated with insect repellent, with edges tucked in under the mattress. The mesh size should be less than 1.5 mm. If the sleeping area is not otherwise protected, use a mosquito coil, which fills the room with insecticide through the night.

To prevent sandfly bites, follow the same precautions as for mosquito bites, except that netting must be finer-mesh (at least 18 holes to the linear inch) since sandflies are smaller.

Revisions

<categorytext name="InsectTickProtection">
 
 Insect and Tick Protection
 
 Wear long sleeves, long pants, hats and shoes (rather than sandals). Apply <a href="/mdtravelhealth/resource/insect_repellents">insect repellents</a> containing 25-50% DEET (N,N-diethyl-3-methylbenzamide) or 20% picaridin (Bayrepel) to exposed skin (but not to the eyes, mouth, or open wounds). DEET may also be applied to clothing. Products with a lower concentration of either repellent need to be repplied more frequently. Products with a higher concentration of DEET carry an increased risk of neurologic toxicity, especially in children, without any additional benefit. Do not use either DEET or picaridin on children less than two years of age. For additional protection, apply permethrin-containing compounds to clothing, shoes, and bed nets. Permethrin-treated clothing appears to have little toxicity. Don't sleep with the window open unless there is a screen. If sleeping outdoors or in an accommodation that allows entry of mosquitoes, use a bed net, preferably impregnated with insect repellent, with edges tucked in under the mattress. The mesh size should be less than 1.5 mm. If the sleeping area is not otherwise protected, use a mosquito coil, which fills the room with insecticide through the night. 
 To prevent sandfly bites, follow the same precautions as for mosquito bites, except that netting must be finer-mesh (at least 18 holes to the linear inch) since sandflies are smaller.
</categorytext>

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General Advice You can't Edit

8

General advice

Bring adequate supplies of all medications in their original containers, clearly labeled. Carry a signed, dated letter from the primary physician describing all medical conditions and listing all medications, including generic names. If carrying syringes or needles, be sure to carry a physician's letter documenting their medical necessity.Pack all medications in hand luggage. Carry a duplicate supply in the checked luggage. If you wear glasses or contacts, bring an extra pair. If you have significant allergies or chronic medical problems, wear a medical alert bracelet.

Make sure your health insurance covers you for medical expenses abroad. If not, supplemental insurance for overseas coverage, including possible evacuation, should be seriously considered. If illness occurs while abroad, medical expenses including evacuation may run to tens of thousands of dollars. For a list of travel insurance and air ambulance companies, go to Medical Information for Americans Traveling Abroad on the U.S. State Department website. Bring your insurance card, claim forms, and any other relevant insurance documents. Before departure, determine whether your insurance plan will make payments directly to providers or reimburse you later for overseas health expenditures. The Medicare and Medicaid programs do not pay for medical services outside the United States.

Pack a personal medical kit, customized for your trip (see description). Take appropriate measures to prevent motion sickness and jet lag, discussed elsewhere. On long flights, be sure to walk around the cabin, contract your leg muscles periodically, and drink plenty of fluids to prevent blood clots in the legs. For those at high risk for blood clots, consider wearing compression stockings.

Avoid contact with stray dogs and other animals. If an animal bites or scratches you, clean the wound with large amounts of soap and water and contact local health authorities immediately. Wear sun block regularly when needed. Use condoms for all sexual encounters. Ride only in motor vehicles with seat belts. Do not ride on motorcycles.

Revisions

<categorytext name="GeneralAdvice">
 
 General advice
 
 Bring adequate supplies of all medications in their original containers, clearly labeled. Carry a signed, dated letter from the primary physician describing all medical conditions and listing all medications, including generic names. If carrying syringes or needles, be sure to carry a physician's letter documenting their medical necessity.Pack all medications in hand luggage. Carry a duplicate supply in the checked luggage. If you wear glasses or contacts, bring an extra pair. If you have significant allergies or chronic medical problems, wear a medical alert bracelet. 
 Make sure your health insurance covers you for medical expenses abroad. If not, supplemental insurance for overseas coverage, including possible evacuation, should be seriously considered. If illness occurs while abroad, medical expenses including evacuation may run to tens of thousands of dollars. For a list of travel insurance and air ambulance companies, go to Medical Information for Americans Traveling Abroad on the U.S. State Department website. Bring your insurance card, claim forms, and any other relevant insurance documents. Before departure, determine whether your insurance plan will make payments directly to providers or reimburse you later for overseas health expenditures. The Medicare and Medicaid programs do not pay for medical services outside the United States.
 Pack a personal <a href="/mdtravelhealth/resource/medical_kit">medical kit</a>, customized for your trip (see description). Take appropriate measures to prevent <a href="/mdtravelhealth/resource/motion_sickness">motion sickness</a> and <a href="/mdtravelhealth/resource/jet_lag">jet lag</a>, discussed elsewhere. On long flights, be sure to walk around the cabin, contract your leg muscles periodically, and drink plenty of fluids to prevent <a href="/mdtravelhealth/resource/deep_vein_thrombosis">blood clots</a> in the legs. For those at high risk for blood clots, consider wearing compression stockings.
 Avoid contact with stray dogs and other animals. If an animal bites or scratches you, clean the wound with large amounts of soap and water and contact local health authorities immediately. Wear sun block regularly when needed. Use condoms for all sexual encounters. Ride only in motor vehicles with seat belts. Do not ride on motorcycles.
 

</categorytext>

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Ambulance You can't Edit

9

Ambulance and Emergency Services

For a public ambulance in Peru, call 141. For a private ambulance, which usually offers better service, look in the local telephone directory or call one of the following:

Alerta Medica (tel. 225-4040)
San Cristóbal (tel. 440-0200)
Plan Vital (tel. 241-1911)
Servimedic (tel. 332-6720)
Alfa Medic (tel. 362-9519)
Mision Medica (tel. 346-2929)

Medical Facilities You can't Edit

10

Medical facilities

In general, private clinics offer better care than the public hospitals. There are several high-quality medical clinics in Lima that are open 24/7 for medical emergencies. They also function as hospitals and offer subspecialty consultations. Many travelers go to one of the following:

Clinica Anglo Americana (Alfredo Salazar, 3rd block, San Isidro; tel. 221-3656; also urgent care center at Av. La Fontana, La Molina; tel. 436-9933)
Clinica San Borja (Av. Guardia Civil 333, San Borja; tel. 475-3141; website www.clinicasanborja.com.pe/)
Clinica El Golf (Av. Aurelio Miro Quesada 1030, San Isidro; tel. 264-3300)
Clinica Montesur (Av. El Polo, Monterrico; tel. 436-3630; specializes in women’s issues)

For a guide to English-speaking physicians and dentists in private practice in Lima, as well as additional clinics, go to the U.S. Embassy website. Adequate medical care is generally available in other cities, but may be difficult to locate in rural areas. In Cusco, there are several private clinics that provide acceptable care, but serious medical problems generally require transport to Lima. Most doctors and hospitals will expect payment in cash, regardless of whether you have travel health insurance. Life-threatening medical problems will require air evacuation to a country with state-of-the-art medical facilities.

According to the U.S. State Department, "Over the last few years, at least five American citizen visitors have died during liposuction operations in Peru. While some of these deaths occurred in ill-equipped, makeshift clinics, travelers are urged to carefully assess the risks of having this type of surgery performed overseas, even when opting for a treatment at one of the better-known clinics."

Revisions

<categorytext name="MedicalFacilities">
 
 Medical facilities
 
 In general, private clinics offer better care than the public hospitals. There are several high-quality medical clinics in Lima that are open 24/7 for medical emergencies. They also function as hospitals and offer subspecialty consultations. Many travelers go to one of the following:
 <ul>
 <li>Clinica Anglo Americana (Alfredo Salazar, 3rd block, San Isidro; tel. 221-3656; also urgent care center at Av. La Fontana, La Molina; tel. 436-9933)</li>
 <li>Clinica San Borja (Av. Guardia Civil 333, San Borja; tel. 475-3141; website www.clinicasanborja.com.pe/)</li>
 <li>Clinica El Golf (Av. Aurelio Miro Quesada 1030, San Isidro; tel. 264-3300)</li>
 <li>Clinica Montesur (Av. El Polo, Monterrico; tel. 436-3630; specializes in women’s issues)</li>
 </ul>
 For a guide to English-speaking physicians and dentists in private practice in Lima, as well as additional clinics, go to the <a href="http://lima.usembassy.gov/uploads/images/7Ih9QlOYH9nKYrDGctYbCg/medicalresources.pdf">U.S. Embassy</a> website. Adequate medical care is generally available in other cities, but may be difficult to locate in rural areas. In Cusco, there are several private clinics that provide acceptable care, but serious medical problems generally require transport to Lima. Most doctors and hospitals will expect payment in cash, regardless of whether you have travel health insurance. Life-threatening medical problems will require air evacuation to a country with state-of-the-art medical facilities.
 According to the <a href="http://travel.state.gov/travel/cis_pa_tw/cis/cis_998.html">U.S. State Department</a>, "Over the last few years, at least five American citizen visitors have died during liposuction operations in Peru. While some of these deaths occurred in ill-equipped, makeshift clinics, travelers are urged to carefully assess the risks of having this type of surgery performed overseas, even when opting for a treatment at one of the better-known clinics."
</categorytext>

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Pharmacies You can't Edit

11

Pharmacies

Most pharmacies in Lima are well-supplied. Many travelers go to one of the following:

Pharmax (Av. La Encalada 1541, Nonterrico, across the street from the U.S. Embassy; tel. 434-1460; 24-hour delivery service)
Pharmax (Av. Salaverry 3100, San Isidro; tel. 264-2282; 24-hour delivery service)
Farmacia Deza (Av. Conquistadores 1140, San Isidro; tel. 440-3798; 24-hour delivery service)
Las Colonias (Santa Elena Norte 102-104 Street, Monterrico, 21st block of Primavera Av. by the Museo de Oro; English-speaking owner)

Many of the major supermarkets, including Wong and Santa Isabel, include good pharmacies.

Blood Supply You can't Edit

12

Blood supply

Screening for HIV and hepatitis remains inadequate. In September 2007, four people were found to have become infected with HIV from blood transfusions at public hospitals. At around the same time, thirty people who went to a social security dialysis center were found to have become infected with hepatitis C (see ProMED-mail, September 14, 2007). Transfusions in Peru should be avoided if at all possible.

Travel with children You can't Edit

13

Traveling with children

Make sure you have the names and contact information for qualified medical personnel before you go abroad (see the U.S. Embassy website).

In general, the recommendations for infants and young children are the same as those for adults, except that certain vaccines and medications should not be administered to this age group. Most importantly, yellow fever vaccine is not approved for use in those under age nine months. Unless there is an extraordinary need to do so, children less than nine months of age should not be brought to areas where yellow fever occurs.

The recommendations for malaria prophylaxis are the same for young children as for adults, except that (1) dosages are lower; and (2) doxycycline should be avoided. DEET-containing insect repellents are not advised for children under age two, so it's particularly important to keep children in this age group well-covered to protect them from mosquito bites.

Food and water precautions, which are recommended for all travelers, must be strictly followed at all times, because diarrhea is especially dangerous in this age group and because the vaccines for hepatitis A and typhoid fever are not approved for children less than two years of age.

All children should be up-to-date on routine childhood immunizations, as recommended by the American Academy of Pediatrics. Children who are 12 months or older should receive a total of 2 doses of MMR (measles-mumps-rubella) vaccine, separated by at least 28 days, before international travel. Children between the ages of 6 and 11 months should be given a single dose of measles vaccine. MMR vaccine may be given if measles vaccine is not available, though immunization against mumps and rubella is not necessary before age one unless visiting a country where an outbreak is in progress. Children less than one year of age may also need to receive other immunizations ahead of schedule (see the accelerated immunization schedule).

Revisions

<categorytext name="Travelwithchildren">
 
 Traveling with children
 
 Make sure you have the names and contact information for qualified medical personnel before you go abroad (see the U.S. Embassy website). 
 In general, the recommendations for infants and young children are the same as those for adults, except that certain vaccines and medications should not be administered to this age group. Most importantly, <a href="/mdtravelhealth/resource/yellow_fever">yellow fever</a> vaccine is not approved for use in those under age nine months. Unless there is an extraordinary need to do so, children less than nine months of age should not be brought to areas where yellow fever occurs.
 The recommendations for <a href="/mdtravelhealth/resource/malaria">malaria</a> prophylaxis are the same for young children as for adults, except that (1) dosages are lower; and (2) doxycycline should be avoided. DEET-containing insect repellents are not advised for children under age two, so it's particularly important to keep children in this age group well-covered to protect them from mosquito bites.
 
 <a href="/mdtravelhealth/resource/food_water">Food and water precautions</a>, which are recommended for all travelers, must be strictly followed at all times, because diarrhea is especially dangerous in this age group and because the vaccines for <a href="/mdtravelhealth/resource/hepatitis_a">hepatitis A</a> and <a href="/mdtravelhealth/resource/typhoid_fever">typhoid fever</a> are not approved for children less than two years of age.
 All children should be up-to-date on routine childhood immunizations, as recommended by the <a href="http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5751a5.htm">American Academy of Pediatrics</a>. Children who are 12 months or older should receive a total of 2 doses of MMR (measles-mumps-rubella) vaccine, separated by at least 28 days, before international travel. Children between the ages of 6 and 11 months should be given a single dose of measles vaccine. MMR vaccine may be given if measles vaccine is not available, though immunization against mumps and rubella is not necessary before age one unless visiting a country where an outbreak is in progress. Children less than one year of age may also need to receive other immunizations ahead of schedule (see the accelerated immunization schedule). 
</categorytext>

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Travel and pregnancy You can't Edit

14

Travel and pregnancy

International travel should be avoided by pregnant women with underlying medical conditions, such as diabetes or high blood pressure, or a history of complications during previous pregnancies, such as miscarriage or premature labor. For pregnant women in good health, the second trimester (18–24 weeks) is probably the safest time to go abroad and the third trimester the least safe, since it's far better not to have to deliver in a foreign country.

Before departure, make sure you have the names and contact information for physicians, clinics, and hospitals where you can obtain emergency obstetric care if necessary (see the U.S. Embassy website). In general, pregnant women should avoid traveling to countries which do not have modern facilities for the management of premature labor and other complications of pregnancy.

Yellow fever vaccine, which consists of live virus, should not in general be given to pregnant women. Unless absolutely necessary, pregnant women should not travel to areas where yellow fever occurs.

Pregnant women should also avoid areas where malaria is transmitted. Malaria may cause life-threatening illness in both the mother and the unborn child. None of the currently available prophylactic medications is 100% effective. If travel to malarious areas is unavoidable, insect protection measures must be strictly followed at all times. The recommendations for DEET-containing insect repellents are the same for pregnant women as for other adults. Of the currently available drugs for malaria prophylaxis, Mefloquine (Lariam) may be given if necessary in the second and third trimesters, but should be avoided in the first trimester. There are no data regarding the safety of atovaquone/proguanil (Malarone) during pregnancy, so the drug should be avoided pending further information. Doxycycline may interfere with fetal bone development and should not be given during pregnancy.

Strict attention to food and water precautions is especially important for the pregnant traveler because some infections, such as listeriosis, have grave consequences for the developing fetus. Additionally, many of the medications used to treat travelers' diarrhea may not be given during pregnancy. Quinolone antibiotics, such as ciprofloxacin (Cipro) and levofloxacin (Levaquin), should not be given because of concern they might interfere with fetal joint development. Data are limited concerning trimethoprim-sulfamethoxazole, but the drug should probably be avoided during pregnancy, especially the first trimester. Options for treating travelers' diarrhea in pregnant women include azithromycin and third-generation cephalosporins. For symptomatic relief, the combination of kaolin and pectin (Kaopectate; Donnagel) appears to be safe, but loperamide (Imodium) should be used only when necessary. Adequate fluid intake is essential.

Travel to altitudes greater than 4000 meters (13,100 feet) should be avoided during pregnancy. During the third trimester and during high-risk pregnancies, travel should be limited to altitudes less than 2500 meters (8200 feet).

Revisions

<categorytext name="Travelandpregnancy">
 
 Travel and pregnancy
 
 International travel should be avoided by pregnant women with underlying medical conditions, such as diabetes or high blood pressure, or a history of complications during previous pregnancies, such as miscarriage or premature labor. For pregnant women in good health, the second trimester (18–24 weeks) is probably the safest time to go abroad and the third trimester the least safe, since it's far better not to have to deliver in a foreign country.
 Before departure, make sure you have the names and contact information for physicians, clinics, and hospitals where you can obtain emergency obstetric care if necessary (see the U.S. Embassy website). In general, pregnant women should avoid traveling to countries which do not have modern facilities for the management of premature labor and other complications of pregnancy. 
 
 <a href="/mdtravelhealth/resource/yellow_fever">Yellow fever</a> vaccine, which consists of live virus, should not in general be given to pregnant women. Unless absolutely necessary, pregnant women should not travel to areas where yellow fever occurs.
 Pregnant women should also avoid areas where <a href="/mdtravelhealth/resource/malaria">malaria</a> is transmitted. Malaria may cause life-threatening illness in both the mother and the unborn child. None of the currently available prophylactic medications is 100% effective. If travel to malarious areas is unavoidable, insect protection measures must be strictly followed at all times. The recommendations for DEET-containing insect repellents are the same for pregnant women as for other adults. Of the currently available drugs for malaria prophylaxis, Mefloquine (Lariam) may be given if necessary in the second and third trimesters, but should be avoided in the first trimester. There are no data regarding the safety of atovaquone/proguanil (Malarone) during pregnancy, so the drug should be avoided pending further information. Doxycycline may interfere with fetal bone development and should not be given during pregnancy.
 Strict attention to <a href="/mdtravelhealth/resource/food_water">food and water precautions</a> is especially important for the pregnant traveler because some infections, such as listeriosis, have grave consequences for the developing fetus. Additionally, many of the medications used to treat travelers' diarrhea may not be given during pregnancy. Quinolone antibiotics, such as ciprofloxacin (Cipro) and levofloxacin (Levaquin), should not be given because of concern they might interfere with fetal joint development. Data are limited concerning trimethoprim-sulfamethoxazole, but the drug should probably be avoided during pregnancy, especially the first trimester. Options for treating travelers' diarrhea in pregnant women include azithromycin and third-generation cephalosporins. For symptomatic relief, the combination of kaolin and pectin (Kaopectate; Donnagel) appears to be safe, but loperamide (Imodium) should be used only when necessary. Adequate fluid intake is essential. 
 Travel to altitudes greater than 4000 meters (13,100 feet) should be avoided during pregnancy. During the third trimester and during high-risk pregnancies, travel should be limited to altitudes less than 2500 meters (8200 feet).	
</categorytext>

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Maps You can't Edit

15

Maps

Helpful maps are available in the University of Texas Perry-Castaneda Map Collection and the United Nations map library. If you have the name of the town or city you'll be visiting and need to know which state or province it's in, you might find your answer in the Getty Thesaurus of Geographic Names.

Embassy You can't Edit

16

Embassy/Consulate Location

(reproduced from the U.S. State Dept. Consular Information Sheet)

U.S. citizens living in or visiting Peru are encouraged to register at the Consular Section of the U.S. Embassy in Lima and obtain updated information on travel and security in Peru. The Consular Section is open for American Citizen Services, including registration, from 8:00 a.m. to 12:00 noon weekdays, excluding U.S. and Peruvian holidays. The U.S. Embassy is located in Monterrico, a suburb of Lima, at Avenida Encalada, Block Seventeen; telephone 51-1-434-3000 during business hours (8:00 a.m. to 5:00 p.m.), or 51-1-434-3032 for after-hours emergencies; fax 51-1-434-3065, or 434-3037, or 434-4182 (American Citizen Services Unit); Internet web site - http://peru.usembassy.gov. This website provides information, but it does not yet have interactive capability to respond to specific inquiries. The U.S. Consular Agency in Cusco is located in the Binational Center (Instituto Cultural Peruana Norte Americano, ICPNA) at Avenida Tullumayo 125; telephone 51-84-24-5102; fax 51-84-23-35-41; cellular phone 51-84-9-62-1369; Internet address consagentcuzco@terra.com.pe. The Consular Agency can provide information and assistance to U.S. citizen travelers who are victims of crime or need other assistance, but it cannot replace lost or stolen U.S. passports, which are processed at the U.S. Embassy in Lima.

Revisions

<categorytext name="Embassy">
 
 Embassy/Consulate Location
 
 (reproduced from the <a href="http://travel.state.gov/travel/cis_pa_tw/cis/cis_998.html">U.S. State Dept. Consular Information Sheet</a>)
 U.S. citizens living in or visiting Peru are encouraged to register at the Consular Section of the <a href="http://lima.usembassy.gov/">U.S. Embassy in Lima</a> and obtain updated information on travel and security in Peru. The Consular Section is open for American Citizen Services, including registration, from 8:00 a.m. to 12:00 noon weekdays, excluding U.S. and Peruvian holidays. The U.S. Embassy is located in Monterrico, a suburb of Lima, at Avenida Encalada, Block Seventeen; telephone 51-1-434-3000 during business hours (8:00 a.m. to 5:00 p.m.), or 51-1-434-3032 for after-hours emergencies; fax 51-1-434-3065, or 434-3037, or 434-4182 (American Citizen Services Unit); Internet web site - http://peru.usembassy.gov. This website provides information, but it does not yet have interactive capability to respond to specific inquiries. The U.S. Consular Agency in Cusco is located in the Binational Center (Instituto Cultural Peruana Norte Americano, ICPNA) at Avenida Tullumayo 125; telephone 51-84-24-5102; fax 51-84-23-35-41; cellular phone 51-84-9-62-1369; Internet address <a href="mailto:consagentCusco@terra.com.pe">consagentcuzco@terra.com.pe</a>. The Consular Agency can provide information and assistance to U.S. citizen travelers who are victims of crime or need other assistance, but it cannot replace lost or stolen U.S. passports, which are processed at the U.S. Embassy in Lima.
</categorytext>

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Safety Information You can't Edit

17

Safety information

For information on safety and security, go to the U.S. Department of StateMD Travel Health>, United Kingdom Foreign and Commonwealth Office, Foreign Affairs Canada, and the Australian Department of Foreign Affairs and Trade.

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